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***GENERAL INSPECTION***
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AAOx3?
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If "NO", explain:
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Patient Physique
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Posture Unremarkable?
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If "NO", explain:
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Skin Unremarkable?
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If "NO", explain:
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Gait Unremarkable?
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If "NO", explain:
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Are They Using an Assistive Device?
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If "YES", what kind?
• • •
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Are There Functional Limitations Present?
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If "YES", explain:
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Notes
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***NEUROLOGICAL EXAMINATION***
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C/T-Spine MYOTOMES Unremarkable?
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Cervical Flexion/Extension (C1/2)
• • •
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Cervical Lateral Flexion (C3)
• • •
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Shoulder Elevation (C4)
• • •
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Shoulder Abduction (C5)
• • •
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Elbow Flexion/Wrist Extension (C6)
• • •
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Elbow Extension/Wrist Flexion (C7)
• • •
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Finger Flexion (C8)
• • •
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Finger Abduction (T1)
• • •
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Other
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C/T-Spine DERMATOMES Unremarkable?
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C2
• • •
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C3
• • •
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C4
• • •
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C5
• • •
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C6
• • •
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C7
• • •
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C8
• • •
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T1
• • •
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Other
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UE Deep Tendon Reflexes
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Biceps (C5/6)
• • •
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Brachioradialis (C6)
• • •
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Triceps (C7)
• • •
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Other
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L/S-Spine MYOTOMES Unremarkable?
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Hip Flexion (L2)
• • •
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Knee Extension (L3)
• • •
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Ankle Dorsiflexion/Inversion (L4)
• • •
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Great Toe Extension (L5)
• • •
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Ankle Plantarflexion/Eversion (S1)
• • •
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Knee Flexion (S2)
• • •
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Other
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L/S-Spine DERMATOMES Unremarkable?
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L2
• • •
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L3
• • •
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L4
• • •
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L5
• • •
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S1
• • •
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S2
• • •
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Other
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LE Deep Tendon Reflexes
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Patellar Tendon (L4)
• • •
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Medial Hamstring Tendon (L5)
• • •
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Achilles Tendon (S1)
• • •
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Other
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Upper Motor Neuron Tests
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Babinski Reflex
• • •
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Romberg's Test
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Other
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Timed Up and Go (TUG) Test
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Time to Complete (seconds)
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Test Findings
• • •
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Notes
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